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Background  Safety of evacuation is of paramount importance in disaster planning for elderly people; however, little effort has been made to investigate evacuation-related mortality risks. After the Fukushima Daiichi Nuclear Plant accident we conducted a retrospective cohort survival survey of elderly evacuees.    Methods  A total of 715 residents admitted to five nursing homes in Minamisoma city, Fukushima Prefecture in the five years before 11th March 2011 joined this retrospective cohort study. Demographic and clinical characteristics were drawn from facility medical records. Evacuation histories were tracked until the end of 2011. The evacuation's impact on mortality was assessed using mortality incidence density and hazard ratios in Cox proportional hazards regression.    Results  Overall relative mortality risk before and after the earthquake was 2.68 (95% CI: 2.04–3.49). There was a substantial variation in mortality risks across the facilities ranging from 0.77 (95% CI: 0.34–1.76) to 2.88 (95% CI: 1.74–4.76). No meaningful influence of evacuation distance on mortality was observed although the first evacuation from the original facility caused significantly higher mortality than subsequent evacuations, with a hazard ratio of 1.94 (95% CI: 1.07–3.49).    Conclusion  High mortality, due to initial evacuation, suggests that evacuation of the elderly was not the best life-saving strategy for the Fukushima nuclear disaster. Careful consideration of the relative risks of radiation exposure and the risks and benefits of evacuation is essential. Facility-specific disaster response strategies, including in-site relief and care, may have a strong influence on survival. Where evacuation is necessary, careful planning and coordination with other nursing homes, evacuation sites and government disaster agencies is essential to reduce the risk of mortality.

Mortality Risk amongst Nursing Home Residents Evacuated after the Fukushima Nuclear Accident: A Retrospective Cohort Study